Melanoma is a sometimes deadly and always dreaded form of skin cancer. It is the third most common cancer in people, especially young women, from the ages of 15 to 39 years old. Young women account for about 66% of the cases of melanoma in the U.S.

What is Melanoma?

Melanoma is a skin cancer that starts in the cells of the skin (melanocytes) that produce melanin, which gives the skin its color. It can start on any area of the skin, including areas that are not exposed to the sun.

It is a very virulent strain of skin cancer so early diagnosis is key to treating and curing melanoma, which often grows and spreads to other parts of the body. The spread of melanoma makes treatment much more difficult to treat. According to the American Cancer Society, melanoma accounts for 10,000 of the 13,000 skin cancer deaths every year in the U.S.

The Increased Number of Cases

Since the 1970′s, there has been a dramatic increase in the number of cases of melanoma in the U.S. The greatest increase, a dramatic 250%, has been diagnosed specifically among children and young adults. This is an alarming statistic.

The most susceptible population seems to be young women, who represent about two-thirds of the diagnosed melanoma cases. The main cause of the uptick in melanoma cases is being associated with the unsafe tanning practices that this particular population follows, which include sunbathing and the increase in indoor tanning. Indoor tanning is just as dangerous, with regard to developing skin cancer, as the natural ultraviolet rays (UV rays) from the sun.

The Survival Rates for Melanoma

Despite the increased number of melanoma cases, there is good news in the survival rate statistics for the sometimes-deadly disease. The survival rate after diagnosis was only about 85% in the mid-1970 but moving forward from 2011, it has increased to about a 95% survival rate.

Treatment choices for melanoma depend upon the stage of the disease and if there has been any metastasis to other areas of the body.The treatment options include, but are not limited to, surgical removal of the tumor and any associated lymph nodes,?chemotherapy, radiation, biotherapy or immunotherapy and targeted drug therapy. Sometimes, a combination of treatments is the best option for effective recovery.

Addressing the Problem

The risk of developing melanoma, which has become a national health concern, needs to be openly addressed by parents, healthcare providers, health educators and anyone else with a voice to, especially, the younger population.

There needs to be increased awareness of the potential dangers from sun exposure and also lessons in effective prevention techniques, such as conscientious and consistent use of sunscreen, not being outside in direct sun exposure during the peak hours of 10 AM to 2 PM, frequent self skin checks to determine any change in a mole or pigmented area on the skin, annual professional skin checks and, preferably, avoidance of sun exposure.

Genetic and environmental risks of developing this type of skin cancer, melanoma, should be evaluated. Skin cancer screenings, which foster early detection, are vital to prevention of this potentially deadly disease.

Prevention is critical and can help to reduce and, hopefully, keep the melanoma statistics lower than the current trend of the disease.

The yearly flu vaccine formula is the U.S Centers for Disease Control and Prevention’s (CDC) best guess to protect everyone from the flu. The vaccine’s composition is determined months ahead of the upcoming flu season, so it really is a guess about what flu stains will be actively and virulently circulating each year.

The flu vaccine formula is determined in about February of the current year and vaccine manufacturing begins in the early summer months, in order to give the pharmaceutical companies enough time to manufacture the millions of doses needed to protect the U.S. population.

2014-2015 Flu Vaccine

The 2014-2015 flu vaccine was less than a perfect match for the circulating influenza strains so the CDC is making adjustments for the upcoming 2015-2016 flu season. The actual threat and then presence of the H3N2 strain was not determined until the summer of 2014, hence it was not included in the 2014-2015 vaccine. Once it was determined to be a health threat, there was not sufficient time to incorporate the H3N2 strain into last year’s flu vaccine.

The 2014-2015 vaccine was determined to be only 18.6% effective against the H3N2 virus, which was the season’s most virulent strain of influenza. Deaths from the H3N2 flu strain were unusually high, especially among the elderly and pediatric populations.

2015-2016 Flu Vaccine

According to the CDC, as stated in a recent Morbidity and Mortality Weekly Report, components of the 2015-2016 season vaccine have been changed to more optimally match circulating viruses. There will be broader protection against the flu with the updated 2015-2016 vaccine composition.

The 2015-2016 flu vaccine will protect against the currently predicted strains that are circulating, which include two influenza type A viruses, H1N1 (the cause of the 2009 pandemic flu) and H3N2, plus an influenza B virus making it a quadrivalent vaccine.

There is no guarantee, according to authorities at the U.S. Centers for Disease and Prevention, that another, unpredicted flu strain, which is not included in the 2015-2016 vaccine, will emerge and gain strength leaving the population unprotected against it.

Quadrivalent Flu Vaccine

There is and has been a quadrivalent flu vaccine available in the past, which protects against four flu viruses, instead of the traditional three viruses found in the most commonly administered immunizations. This vaccine covers two influenza A viruses and two influenza B viruses. It is especially recommended for those at a high risk of complications from the flu, which include immuno-suppressed, elderly and others with chronic medical conditions.

Who Should Be Vaccinated?

The CDC recommends that everyone 6 months and older be vaccinated against the flu every year. There are exceptions to this recommendation, which should be discussed with every patient’s primary care physician.

The current year’s flu vaccine is usually available sometime in September. There should be lines of patients waiting to be immunized as soon as the vaccine is available.

An important caveat of which to be aware is that, even if the vaccine is not a perfect match to the circulating flu viruses, it remains the best protection available against the sometimes-deadly influenza viruses, whatever they might be in a given year.

There are a lot of patients who declare that they eat a gluten-free diet, whether diagnosed with celiac disease or not. Gluten clearly causes many gastrointestinal issues but it is an imperative diet omission for anyone who is diagnosed with celiac disease.

There are almost 3 million Americans who are actually diagnosed with celiac disease. Those patients must avoid all gluten in their diet.

Many food products are labeled as “gluten-free,” but are they truly void of gluten? The U.S. Food and Drug Administration (FDA) is making a special effort to be sure that they are.

Gluten 101

Many food products are labeled as “gluten free,” but are they truly void of gluten? The US Food and Drug Administration (FDA) is making a special effort to be sure that they are absolutely gluten-free.

Gluten is a collection of proteins that are found in wheat, rye, barley and crossbreeds of each of these grains. It helps baked goods to have a light and flaky texture.

Celiac Disease Explained

Celiac disease is an autoimmune disease, which has no cure but is most simply and initially treated by eating a “gluten-free” diet.

Gluten is disruptive for patients with celiac disease. It enhances the production of antibodies that negatively affect and potentially damage the lining of the small intestine. This, in turn, lowers the patient’s ability to absorb important nutrients from their usual diet. When important nutrients are not absorbed, there are serious impending and potential health risks including osteoporosis, infertility, intestinal cancers and more.

Avoiding gluten helps patients with celiac disease to have better control of their symptoms. The symptoms include abdominal pain, bloating, diarrhea, weight loss, fatigue, rashes and other long-term medical problems.

FDA and Gluten-Free

The FDA is working to be sure that food labels that read “gluten-free” truly meet the criteria of their definition, which is less than 20 parts per million of gluten. Other label wording like “no gluten”, “free of gluten” and “without gluten”must also meet the full “gluten-free” FDA requirements.

Until recently, the FDA did not regulate any of the “gluten-free” foods; instead, manufacturers had their own interpretation of the term and labeled foods as “gluten-free” at will.

It is important that patients who do not have professionally diagnosed celiac disease to continue to eat gluten so they do not develop a nutrient deficiency. In this world of self-diagnosis, there are many patients whom have declared themselves “gluten-free” without a confirmed diagnosis by a qualified physician.

Many gluten-free foods are higher in calorie than non-gluten-free choices. This fact can lead to weight gain, which should be monitored in the long-term.

In Conclusion

The U.S. government is taking celiac disease very seriously. There are standards to which all food manufacturers will be held accountable, according to the FDA regulations.?Food manufacturers must adhere to the “gluten-free” regulations imposed by the U.S Food and Drug Administration in order to keep the affected population healthy and safe.

Cancer and heart disease kill more Americans than any other medical conditions. But interestingly, they are not as expensive to treat and care for as dementia, especially Alzheimer’s disease.

There are an estimated 4.1 million, according to the National Institute on Aging survey, to 5.2 million, according to the Alzheimer’s Association, Americans suffering from some form of dementia. Astoundingly, Alzheimer’s disease costs U.S. families and patients, collectively, somewhere between $157 and $215 billion each year to treat.

The high cost of care for dementia patients is compared to $102 billion spent to treat heart disease and $77 billion spent to treat cancer each year in the U.S.

Alzheimer’s Disease Facts and Figures

There are many numbers assigned to general dementia and Alzheimer’s disease. The most poignant facts include the following:

Alzheimer’s disease is the most common type of dementia

It is the 6th leading cause of death in the United States

Dementia can cause strokes and other serious diseases

Prevalence of the disease is increasing

Treatments only ease the symptoms

Progression of the disease cannot be slowed

There is no cure

Patients usually live anywhere from 4 to 8 years after diagnosed with Alzheimer’s disease, some patients live as long as 20 years

75% of Alzheimer’s patients over 80 years old are living in a nursing home; in the general U.S. population (those without a definitive dementia diagnosis), only 4% of patients are cared for in a nursing home

What Costs So Much?

Patients with Alzheimer’s disease are often on prescribed a variety of medications to help control their symptoms. There are currently no drugs to actually halt or reverse the symptoms of dementia and there is no cure for the disease.

The cost of the drugs and other necessary medical treatments do not mount up the cost to treat the disease as much as the care each patient needs to navigate through everyday life.

While the true cost of dementia care includes everything from medications to nursing home care, the cost would be higher than the authorities state except the statistics do not include informal care and lost wages for family members of dementia patients. The cost of informal care by family members was determined by what the cost for a home health aide would have been for the same number of hours spent with the patient. This expenditure added $41,000 to $56,000 more per patient per year to the cost for dementia patient care.

The Concerns

Dementia robs a patient of their ability to make independent decisions, perform activities of daily living and maintain meaningful interpersonal relationships.

The number of cases of Alzheimer’s disease is trending upward in the U.S., mostly due to a rapidly aging population and fewer young people. It is important to work on two approaches to dealing with the dreaded disease:

Prevent the disease from developing, in the first place

Change the course of the disease, once it does develop

Alzheimer’s disease acutely and adversely affects the patient but also impacts the family, friends and caregivers of the patient. Moving forward, it is important to find the best plan of care to suit the needs of all those involved in each patient’s care.

The past winter weather was harsh, in so many ways. The cold temperatures and the extreme piles of snow made it a record-breaking season in many parts of the country. We will continue to feel the effects, especially, of the record-breaking snow as we pass through the summer months. How is this possible, you ask?

The tiniest of ticks, those troublesome and disease-laden insects, benefitted from the deep snow cover over the winter months. The deep snow cover actually protects tiny insects from the effects of frigid air temperatures. Snow works as an insulating blanket to prevent the ticks from freezing and dying.

The Projection

There is a potential for a higher population of ticks this summer because of the snow protection. The ticks are protected by deep snow cover and do not die off so they go on to survive the summer season ahead.

This phenomenon might be countered by the increasingly arid or dry conditions that have evolved over the recent spring season. The dry conditions can work to keep the tick population better controlled.

Which way will it go? According to public health official, it is too early to tell, for sure.

Lyme Disease

Ticks are everywhere, in the woods and in rural and suburban areas. Ticks carry Lyme disease. There are two primary types of ticks:

Deer or black-legged ticks

Dog ticks

The U.S. Centers for Disease Control and Prevention (CDC) estimates that about 300,000 Americans are diagnosed with Lyme disease every year.

Prevention is the best advice to control the Lyme disease epidemic, especially in the Northeast and upper Midwest areas of the country. Some important prevention tips include:

Avoid areas where ticks are commonly located such as deep grass and wooded areas

Wear insect repellent

Check skin for ticks after spending time outside

Check pets for ticks when they come in from outside

Lyme disease symptoms include, but are not limited to:

Flu-like symptoms

Bull?s-eye shaped rash

Advanced and untreated cases of Lyme disease can lead to more alarming symptoms including, but not limited to:

Cognitive issues

Arthritis

Rarely death

Other Tick-Borne Diseases

Lyme disease is the primary tick-borne disease but there are other concerning illnesses that they can spread, anaplasmosis and babesiosis. Currently, there are 604 cases of anaplasmosis and 520 cases of babesiosis reported in the U.S. each year.

Both diseases can present as flu-like symptoms and potentially lead to death, especially in the elderly population or anyone with a weakened immune system. There is treatment available for these two tick-borne diseases.

One other tick-borne disease, according to the CDC, is Powassan virus. There have been 75 reported cases in the U.S. The symptoms of this disease include:

Headaches

Vomiting

Seizures

Memory loss

Long-term neurological problems

Unfortunately, there is no current treatment for Powassan virus.

It is important to be aware of the potentially serious and active Lyme disease season that lies ahead. Again, prevention is key to stopping cases of Lyme disease from climbing any higher. Be aware, be alert and be sure to do a full skin check when coming inside from the wonderful outside activities of summer. You will be glad that you did.

Pain is real but controlling pain can become unreal. In this world of chronic pain coupled with a rising trend in addiction, there is great concern. It is often difficult to relieve pain without the health risks related to potentially addicting drugs.

Chronic pain comes in all forms from back pain to headaches to joint pain and more. About 50% of Americans report that they experience some sort of chronic pain. The Institute of Medicine confirms that about 116 million adults suffer from chronic pain each year.

The Problem

The U.S. Food and Drug Administration (FDA) recently added warnings to extended-release opiates like OxyContin and Opana ER stating that they should be used only as a last choice of pain treatment. Despite the old adage that, if taken according to a prescription, pain medication is safe, the statement is untrue. Even when taken as directed, there are still an addiction risk, accidental overdoses and potential death from these drugs.

The next step down in medication includes non-steroidal anti-inflammatory drugs like ibuprofen and naproxen. These medications can increase the risk of GI problems like ulcers and internal bleeding. Even acetaminophen, when taken in high doses, can cause liver damage.

Deaths related to drug overdose have increased three-fold over the past quarter century, during which there was a dramatic increase in prescribed opiates. There have been over 1,500 acetaminophen-related deaths in the U.S. over the past 10 years.

Drug Free Solutions for Chronic Pain

Something needs to be done, something drug free, to control chronic pain. What is the solution?

Some doctors have turned to stress management and alternative/integrative medicine. What is available to help control chronic pain? These treatments can be used alone or in combination, depending upon each individual case.

Ice

Heat

Exercise

Massage

Biofeedback

Psychotherapy

Acupuncture

Meditation techniques

Yoga

Tai chi

Hypnosis

Chiropractic treatment

Physical therapy

Occupational therapy

Medical insurance coverage for the drug-free pain control is sometimes a challenge to get approved. Currently, evaluation and mediation counseling are the easiest to get covered while yoga and acupuncture, because they are administered by someone other than a licensed physician, are more difficult to get covered.

Other drug free pain remedies include:

Being in love helps because intense love stimulates the same part of the brain that releases pain-relieving drugs

Pet owners have less pain and improved health because pets reduce stress, lower blood pressure and encourage more social connections

Staying busy helps to control pain like volunteering and focusing on helping others, instead of the chronic pain

Talking, as in cognitive-behavioral therapy, helps to lessen chronic pain

Meditation helps to control breathing and quiet the mind so that chronic pain is better controlled

The Benefits of Drug Free Pain Control

The replacement therapies do not have any side effects, like drugs do. Many of the suggested therapies are self-help techniques, which can be done at home after proper instruction by a therapist.

Physicians are ever more aware of the evolution of drug addiction in the U.S. Drug free chronic pain control techniques need to be of paramount importance to control the alarming rising addiction statistics. This will save a lot of health problems, heartache and, most importantly, the effort will save lives.

Suicide is the 8th leading cause of death in the US. Over 1% of all deaths in the US are the result of suicide. About 30,000 Americans die by suicide every year and another 500,000 unsuccessfully attempt to kill themselves.

Attempted suicide versus completed suicide is at least 10:1. About 30% to 40% of those who successfully kill themselves have made a previous attempt.

The age of suicide victims rises with aging. About 40% of suicide victims are over 60 years old. The rate of suicide is even higher after age 75 at which time it rises to about three times higher than the average rate.

Suicide Risk

Suicide is not discriminating. It can affect the elderly, children, wealthy, poor, celebrity and those who are unknown. Some people have a greater risk than others.

Suicide is the result of a serious mental or emotional disorder. 30% to 70% of suicide victims in the US have severe depression or bipolar disorder. Substance abuse is another big influence on suicide rates; about half of all suicides involve substance abuse.

There are many clues and indicators about a patient’s suicide risk. They include, but are not limited to:

Depression

Talking about killing themselves, feeling trapped, being a burden or having no reason to live

Substance or alcohol abuse

Withdrawing from activities

Loss of interest

Anxiety

Acting recklessly

Giving away belongings

Blood Test Predictor

How else can a patient’s suicide risk be predicted? According to Johns Hopkins University School of Medicine, there is a genetic marker linked to a patient’s susceptibility for suicide. This marker could be used to develop a suicide-diagnosing blood test.

The research documented that there is reduced activity of the SKA2 gene in patients who died from suicide. The SKA2 helps the body respond to stress and controls impulsive behavior. Patients with less active SKA2 genes where more prone to commit suicide than others in the study. The reduced activity is the result of a chemical change, specifically the addition of methyl groups.

Patients with sluggish SKA2 are not able to stop negative thoughts and fears. Patients with higher levels of methylation were found to be more likely suicide victims.

Blood Test Accuracy

Researchers predicted a person’s suicidal thoughts with 80% accuracy with the blood test.

Testing military veterans upon arrival home from deployment and others possibly at risk can help to predict the likelihood of suicide. This blood test can possibly save lives.

Another important use for this blood test is psychiatric emergency room evaluation. It can also be helpful in deciding if certain medications, which have been linked to suicidal thought, are a good choice for some patients. The test will help the prescribing MD and patient make informed treatment decisions before starting a new medication regime.

The Final Word?

So how does this blood test really work? Actual chemical changes to the SKA2 gene, which is directly linked to the body’s stress response, might predict a patient’s risk of attempting suicide.

Remembering to take daily medication can be difficult for some patients. Which pill do I take when? This becomes a consummate question, not only in younger years but especially when a patient is elderly. It holds true for everyone.

Patients who take multiple medications every day are impacted, as are elderly parents for whom many people provide care. Many patients take their medications directly out of the prescription bottle while others choose to fill a daily or weekly medication holder. Either way, there is a chance for error.

Medication Facts

There are many medications ordered on a regular basis in the US. Here are a few interesting facts about the general population and prescription drugs:

32 million Americans or 10% of the population take at least five different prescription drugs on a regular basis

Half of the US population, who takes regular medications, does not take them correctly

Taking medications incorrectly adds $100 billion per year to US healthcare costs

The Medication Dilemma Solution

An innovative start-up pharmacy, PillPack, has come up with a solution to the confusion about taking medication correctly. All prescribed pills are packaged according to the dosing time, not individually by separate prescription.

What is New About It?

Drugs are not sent in the traditional, all-of-one kind pill bottles

All prescribed drugs are sorted together into a clear plastic wrapper, which is printed with the date and time they should be taken

What is the Same?

Prescription drugs are sent to the patient by a mail order system

The cost is about the same as the local pharmacy or traditional mail order pick-up

This system takes the guesswork out of wondering if the patient took each prescribed pill or which prescribed pills were actually taken.

The Benefits

A study was conducted by Walter Reed Army Medical Center in Washington, D.C. to determine the accuracy of taking prescribed medications. The study found that by individualizing medication doses NOT individual meds, the compliance for regularly and accurately taking medications rose from 67% to 97%.

First and foremost, everyone can relax. The patient, the caregiver and concerned family members can be assured that the prescribed dose of each medication is sealed in the PillPack. The guesswork is gone.

The PillPack system eliminates:

Frequent trips to the pharmacy to pick up prescriptions

Sorting through pill bottles

Calling the pharmacy for prescription refills

The Company

PillPack is an independent company started by a pharmacist who wanted to innovate the way prescriptions are dispensed. The Company is licensed in 47 states. Oklahoma, Louisiana and Oregon have not yet approved PillPack usage.

There are 66 employees. Interestingly, 15 of those employees work exclusively on helping new patients transfer their existing prescriptions from traditional pharmacies to the PillPack system.

PillPack’s filling system is similar to one used in hospital pharmacies. The system holds 400 of the most popularly prescribed medications. A pharmacist loads less popular drugs into the PillPack by hand. Both the machine and a pharmacist check each drug.

Up and Coming

PillPack is designing a smartphone app to remind patients to take their medication

The PillPack app will also allow patients to reorder medications via email, instead of calling the pharmacy

This system seems to be worth a try. Will it catch on? There will be more pop-up pharmacies offering the same service in the future. It will be up to the patient to choose the best option to fill their medication needs. Traditional retail pharmacies will need to step up their game in this competitive market.

A non-invasive test for marijuana detection would be a valuable tool in the work environment and for drug-related driving tests. Researchers are also working to develop a saliva test to detect marijuana in a person’s system.

With regard to drug usage, marijuana smokers fall into two categories. “Frequent smokers” are those who imbibe more than three times per week. “Occasional smokers” use marijuana less than twice per week. These guidelines were the basic foundation and participant criteria for the research.

The Need for Testing

Marijuana can be detected in the saliva almost immediately after smoking and for 12 to 24 hours after drug use.

Currently, urine tests are the most common means by which to screen for the drug. Obtaining a urine sample has drawbacks including privacy and the validity of the specimen sample. For obvious reasons, no one observes the collection of a urine sample. Guilty parties have been known to submit urine samples, other than their own, in order to pass the drug test.

On the other hand, collecting a saliva sample for analysis allows direct observation while the specimen sample is collected. Therefore, the sample cannot be altered or submitted for another person, which happens more commonly with a urine sample collection.

The Test Itself

Researchers have only screened marijuana smokers, not those who ingest the drug by other means. Users in the study were monitored and tested for 22 hours after smoking marijuana.

There are currently three saliva collection options. The tests include StatSure, Oral-Eze and DrugTest 5000. The first two options require in-laboratory validation while the DrugTest 5000 gives a quick, on-site result.

For legal and professional testing purposes, an in-laboratory confirmed positive drug test result is necessary. The DrugTest 5000 does give a quick reading, which is needed in some cases. Researcher found that the results of each test vary according to each specific ingredient.

The Results of the Test

The drug detection window is shorter for the occasional smoker than it is for the frequent smoker. Also, the drug concentration levels were higher for frequent smokers than those noted for occasional smokers.

Random drug testing in the workplace is the best indicator of marijuana use. The saliva or oral fluid based tests are a useful to detect marijuana usage in the past few days. This type of drug test is used for pre-employment, random, post-accident, reasonable suspicion or return to duty testing.

Studies are still being conducted to validate the accuracy and proper usage of the marijuana detection saliva tests.

Moving forward, it is still to be determined if urine, blood or saliva drug testing is the most accurate, appropriate and timely when assessing marijuana usage.

Is your patient just tired or do they have chronic fatigue syndrome? Think again because chronic fatigue syndrome has been renamed, according to the Institute of Medicine (IOM). The IOM is an independent, nonprofit organization that works to offer medical advice to government authorities and the general public.

The renaming came about because patients felt that their medical condition, chronic fatigue syndrome, was mocked by the former name. This disease is now called systemic exertion intolerance disease (SEID). Either way, whether it is called chronic fatigue syndrome or systemic exertion intolerance disease, has the same troubling symptoms for the patient.

Systemic Exertion Intolerance Disease (SEID) Explained

This disease affects the daily quality of life of those who suffer from it. The level of affect varies from patient to patient, depending upon their symptom list and the severity of their symptoms.

Here are a few facts about the disease:

860,000 to 2.5 million Americans are affected, on some level, by the disease

There is no specific test to diagnose the disease. It is often diagnosed by ruling out other causes of a patient’s symptoms

Many patients with SEID are either housebound or bedridden. Many more are unable to attend school or go to work. It interferes with normal daily life. The symptoms of SEID do not improve with bedrest.

Diagnosing the disease is not an easy task nor is it clear-cut. There is no blood test or body scan to confirm it. The usual diagnostic course includes:

Patient history

Physical exam

Mental exam

Laboratory tests to rule out other potential diagnoses

Patients must have at least four of the above listed symptoms for at least 6 months, before they are specifically diagnosed with chronic fatigue syndrome or SEID.

The Stigma of the Disease

In renaming SEID as disease, not a disorder, a bold statement is made. The intended message is that affected patients are not just lazy or unmotivated; they have a real medical condition. The disease entity focuses on the post-exertional malaise, which is the main symptom and primary patient complaint.

Treating SEID

There is no cure for the disease. The varying symptoms are closely monitored and treated as needed. There is tremendous emotional and physical support and effect from the well-planned treatment by rehabilitation specialists, mental health counselors and physical therapists as needed. Each patient diagnosed with SEID needs an individualized treatment plan moving forward with daily life.